Discharge summaries are getting more attention, as the final link in the chain of evidence that may protect claims from auditors and as a tool to prevent readmis­sions, improve continuity of care and comply with mean­ingful use and core measure requirements. But discharge summaries have evolved with the adoption of electronic health records and the spread of hospitalists, and their quality and integrity could use a fresh look, experts say.

“The time of discharge is a big compliance risk. It can set off an adverse chain of events, including readmis­sions,” said Sandra Routhier, senior healthcare consultant with Panacea Healthcare Solutions, at a Feb. 14 webinar sponsored by RACMonitor.com.

Because discharge summaries are a prime piece of documentation in terms of substantiating the medical necessity of admission and coding diagnoses and pro­cedures, they have to stand up to auditor scrutiny. “The discharge summary is my favorite document in the inpa­tient record,” Routhier said. “It’s where the doctor sum­marizes the whole encounter” (see box, p. 3). Auditors should be able to tell from discharge summaries exactly what they will find in the rest of the medical record — what the patients presented with, what was suspected on admission, what clinicians did for them during the stay and what the plan for discharge is. But electronic health records have brought significant changes to discharge-summary formats, and some of the required elements normally found in a discharge summary dictated by phy­sicians may be missing, Routhier said.

Discharge summaries also are “the handoff docu­ment from hospital to home or the outpatient environ­ment,” George Alex, senior managing consultant at the Berkeley Research Group in Baltimore, said at the webi­nar. “The post-discharge provider may not have access to all the information so the discharge summary must stand on its own.” Studies show that making discharge summaries available to primary care physicians reduces readmissions, Alex said.

The elements of discharge summaries are set forth by CMS and accreditation bodies and incorporated in hospital bylaws. Under the Medicare conditions of par­ticipation (Sec. 482.24(b) and (c)), discharge summaries must include the outcome of the hospitalization, the disposition of care, medications, adverse reactions, com­plications, health care-associated infections, provisions for follow-up and a final diagnosis documented within 30 days — although hospitals are starting to demand it sooner, Routhier and Alex said. The Joint Commission echoes many of these requirements.

Discharge Summaries Are Key to Coding

A lot is riding on discharge summaries in terms of coding and billing. They communicate the clinical infor­mation needed to select principal and secondary diagno­ses, which drive the MS-DRG. Physicians can elaborate on diagnoses — which conditions were confirmed and which were ruled out, Routhier said. Suppose urinary tract infection is documented as a differential diagnosis in the history and physical, but cultures were negative and antibiotics discontinued on the third day. Did the patient have a UTI or not? “If it’s something that impacts the stay and qualifies as a principal or secondary diagno­sis, it is relevant to mention it in the discharge summary,” she said.

But be wary of “surprise diagnoses” in discharge summaries, Routhier said. “Sometimes you see a di­agnosis show up in the discharge summary that’s not supported in the body of the medical record or clinical evidence. It’s suspicious when acute respiratory failure is documented in the discharge summary out of the blue.” Conversely, auditors say sometimes there’s noth­ing about the principal or secondary diagnosis in the discharge summary. “If it’s so significant, why isn’t it in the discharge summary?” Auditors are very skeptical of these claims, although this isn’t necessarily a deal-break­er. “If it isn’t included in the discharge summary, it better be overwhelmingly supported throughout the medical records,” Routhier said. Both problems may be a side effect of electronic health records; physicians could have copied and pasted conditions from a previous admission or pulled in diagnoses from a problem list that hasn’t been properly maintained.

Hospitals should also think twice about discharge summaries that are created by dictation services or pro­viders who did not participate in the care of the patient and then co-signed by attending physicians. “I have encountered facilities that outsource the creation of dis­charge summaries to qualified individuals who review the medical records and then they’re co-signed by the attending. I don’t find those documents are that valuable from a coding or abstracting perspective,” she said. The discharge summary is supposed to finalize the medical record for the inpatient encounter, but that’s not possible unless the attending physician completes it.

A related problem crops up with the growing use of hospitalists, Routhier said. More inpatients are treated by various hospitalists during their stay. While they all con­tribute to the medical record, there can be problems com­pleting a comprehensive discharge summary because there have been so many fingers in the documentation pie, she said.

In terms of the continuum of care, discharge sum­maries are the first and maybe the only communication between the hospital and post-discharge provider (e.g., the primary care physician), Alex said. They are essential to continuity of care, medication reconciliation and pre­venting readmissions and their associated penalties. But hospitals must have a process for identifying post-acute providers and relaying discharge summaries to them, he said. It’s easier when physicians are part of the same electronic health records system. For example, a 21-point electronic template was found in one study to reduce readmissions, identify the primary care physician and improve the quality of the discharge summary, Alex said.

EHRs have changed the discharge summary land­scape, for better and worse. One benefit is that discharge summaries can be completed much faster. “Often hospi­tals have gone from 30 days to seven days to three days to a 24-hour commitment,” Alex said. Some hospitalist contracts have bonuses or penalties linked to timeliness of discharge summary completion. EHRs pave the way because some sections of the discharge summary, such as medication reconciliation, can autopopulate over the course of the hospital stay. “What you will find at dis­charge is the amount of work is less substantial,” he said.

Physicians also use voice recognition or EHRs to create discharge summaries in real time. That’s a far cry from the discharge summaries of the past, which were dictated for later transcription, Routhier said. The speed dovetails nicely with meaningful use requirements. To qualify for incentives under stage I, hospitals must make a copy of discharge instructions at time of discharge in paper format, or, if requested by the patient, in electronic format, Alex said. Stage II meaningful use requires hospitals to “generate and transmit summary of care documents at transition of care and referrals,” the CMS website says.

With EHRs, hospitals can effectively capture e-prescribing and post-discharge orders (e.g., labs, follow-up X-ray) depending on the functionality provided in their EHR system. “It can be prepopulated into the discharge summary without creating a lot of rework for the physician,” Routhier said. And canned text can be dropped into the document when the same type of information needs to be communicated in the discharge summary, such as disease-specific discharge instructions. “But you don’t want a lot of cutting and pasting. We are seeing problem lists pulled in that are not being man­aged effectively,” she said.

It’s important to ensure electronic discharge sum­mary templates are well crafted or they may backfire. If physicians find them confusing or they lack prompts for all the required elements, they will hunt for “work­ arounds” and perhaps undermine the quality of the discharge summary, Alex said.

There’s a monitoring benefit to EHRs, Alex said. How quickly are discharge summaries completed? How often are certain parts completed or neglected? “It gives you information about how to tackle problems,” he said. If certain fields are missed by all physicians, group train­ing is a better approach. But if only a handful of physi­cians always drop the ball, then one-on-one discussions are preferable.

Discharge summaries also figure into core measures, which are CMS quality ratings posted on the Hospital Compare website. CMS tracks hospital compliance with standards of care for certain conditions, such as acute myocardial infarction. If the core-measure requirements have been met — for example, the physician identified a contraindication for prescribing a beta blocker or statin at the time of discharge — but this was not documented in the medical record, there’s always the chance to add it to the discharge summary, Routhier said.

Alex cautioned that there is another core measures angle. Coding every complication and comorbidity doc­umented in the discharge summary, as coders are trained to do, may not turn out well from a core measures per­spective. “You may identify diagnoses that drive up the DRG payment but have unintended consequences on core measures [case selection and reporting],” he said. “That information will be included on the Hospital Com­pare website so you want to come up with a balanced approach.”

Principal Diagnosis (The condition after study that was determined to have led to the admission)

Additional Diagnoses (other comorbid conditions and/or complications that impacted resources consumed during hospitalization; include confirmed diagnoses and those still suspected at the time of discharge)

Surgical or Other Significant Procedures

History of Present Illness (Significant H&P findings, events that resulted in inpatient hospitalization, condition that occasioned the admission)

Hospital Course (summarize the events of the hospitalization — doesn’t need to be a day-by-day, play-by-play. Recommend problem-based vs. chronological. What were the significant events? Tell the story of the hospitalization for each significant medical problem — the beginning, middle and end.)

Patient’s condition/diagnoses (address severity of illness, response to treatment, address any differential diagnoses that were confirmed, ruled out or still uncertain at time of discharge)

Findings and Diagnostics (Summary of significant diagnostic tests and their findings)

Treatment and Procedures (Summary of significant treatments and procedures including medication changes)

Consultations

Complications

Condition on Discharge (Exam on discharge)

Discharge Plan and Instructions

Disposition (Place to which patient was discharged, such as home with home health services or skilled nursing facility)

Nina Youngstrom has been writing The Report on Medicare Compliance since 1992 and has a reputation for being one of the most knowledgeable journalists and incisive writers in the field. With excellent contacts at the IG's office and at CMS, and strong relationships among industry experts and line compliance officers, every week Nina's Report on Medicare Compliance has inside news you won't read anywhere else.